Relations between diabetes status, comorbid conditions, and current mental health in older adult females

Ment Health Fam Med (2018) 13: 715-719 2018 Mental Health and Family Medicine Ltd Research Article Relations between diabetes status, comorbid conditions, and current mental health in older adult females Julia M Forsberg Amanda M Flores Abigail A Plec Savannah K Vincent Jessica L Hartos* ABSTRACT Purpose: Research relates diabetes to mental health conditions, but not to general mental health, especially in specific demographic groups. The purpose of this study was to examine whether current general mental health differs by diabetes status in older adult females in the general population. Methods: This cross-sectional analysis used 2016 data from the Behavioral Risk Factor Surveillance System (BRFSS) for females ages 65-75 from Alabama (N=867), Kentucky (N=1356), Mississippi (N=668), and Texas (N=1714). Multiple logistic regression analysis by state was used to assess the relationship between diabetes status and mental health while controlling for health-related and demographic factors. Results: Across states, about one-fourth of participants reported mental health issues (22-31%) and a diabetes diagnosis (23-26%). In addition, about one-half reported having 2 or more health conditions (41-51%) other than diabetes. The Introduction Mental illness is the largest contributor to disability in the United States and describes a broad variety of emotional and behavioral disorders including anxiety and depression [1]. Recent data shows prevalence rates of up to 11% for depression and up to 15% for anxiety, indicating that these conditions should not be ignored [1-5]. Research indicates that mental illness is higher among women than men, and for those with results of adjusted analyses indicated that mental health was related to diabetes status and healthcare access in two of four states and to number of health conditions in all four states. Conclusion: Overall, current mental health was marginally related to diabetes status and healthcare access, but consistently related to number of health conditions in older adult females. Primary care providers should screen for mental health issues and multiple health conditions, including diabetes, in older adult females who present with either, assess the management of any conditions, and refer to psychiatry or other specialties as appropriate. In additions, providers may need to consider cost as a barrier in treatment plans for older adult females with multiple health issues. Key words: Mental health, Diabetes, Older-adult females, Health conditions lower education, lower socioeconomic status, minority status, and chronic conditions, including diagnosed diabetes [1,6-8]. Diabetes mellitus is also a large contributor to disability worldwide [3]. It is characterized as a metabolic condition in which there is an insufficient amount of insulin or the body is resistant to insulin [3,5,7]. In 2014, 422 million people reported having diabetes mellitus and the prevalence has been increasing in the past three decades worldwide [3]. The prevalence has

716 Forsberg JM, Flores AM, Plec AA also been increasing in the United States with up to 9% of the population reporting a diagnosis of diabetes mellitus [9]. This increase may be related to multiple factors including physical inactivity, poor diet, body weight increases, genetics, hypertension, lower socioeconomic status, and minority status [5,7,10]. Diabetes tends to be comorbid with many medical conditions including metabolic syndrome, eating disorders, anxiety disorders, vision loss, kidney failure, cardiovascular disease, neuropathy, cognitive decline (including dementia and Alzheimer s Disease), and elevated BMI, all of which lead to increased burden on the patient s body [3,5-7,10,11]. Research shows increased rates of mental health problems such as depression and anxiety in diabetics as compared to the general population [8,10-13]. Stress from managing diabetes, diabetes complications, and comorbidities can increase depressive symptoms for individuals ages 55 and older with diabetes, and women report significantly higher distress, depression, and anxiety compared to men [12,14]. Many studies link physical health and specific mental health conditions to diabetes, but there is a lack of data and clinical focus on current general mental health as related to a patient s diabetic status [3-4]. Additionally, there is still limited research for relations between diabetes and mental health within older adult samples [7]. Therefore, the purpose of this study was to examine whether overall mental health differs by diabetes status in older adult females in the general population. Methods Design This cross-sectional analysis used 2016 data from the Behavioral Risk Factor Surveillance System (BRFSS) conducted by the Center for Disease Control and Prevention (CDC) [15]. BRFSS collects annual data from US residents regarding chronic health conditions, health-related risk behaviors, and use of preventative services by telephone survey using random digit dialing (RDD) techniques in all 50 states. Monetary compensation is not provided for BRFSS survey participants. The CDC compiles all BRFSS data and allows researchers access to de-identified data to conduct secondary data analyses. This study was given exempt status by The University of North Texas Health Science Center. Sample The samples included older adult females ages 65 to 75 in Alabama (N=867), Kentucky (N=1356), Mississippi (N=668), and Texas (N=1714). This age group was chosen because there is limited research related to older adults in regard to diabetes and mental health [7]. Further, women were chosen because prevalence of mental illness is higher in women than men [1,6-8]. Lastly, these states were chosen because of their higher proportions of individuals who reported having diabetes and mental health issues as compared to other states based on the BRFSS 2016 prevalence survey data maps [16]. Data The outcome, mental health, was originally measured in BRFSS as the number of not good mental health days in the past 30 days which includes stress, depression, and problems with emotions. The means for this variable in all four states were severely skewed as the mode in each state was 0 days of not good mental health. We reversed this variable to reflect good current mental health and dichotomized it as yes for reporting no days of mental health issues in the past 30 days or no for reporting one or more days of mental health issues in the past 30 days. The factor of interest was diabetes, which was measured as yes/no to having ever been diagnosed with diabetes. Control variables included weight status, health conditions, healthcare access, ethnicity/race, income level, employment status, and education level. Weight status was measured as yes/no to being overweight or obese. The number of health conditions was determined as number of yes responses to diagnoses for any of the following: heart attack, CHD, stroke, skin cancer, other cancer, COPD, arthritis, depression, kidney disease, asthma. This number was then categorized as 0 health conditions, 1 health condition, or 2 or more health conditions other than diabetes. Healthcare access was measured as yes/no to cost precluded seeing a doctor in the past 12 months. Because most participants were white, ethnicity/ race was measured as white, non-hispanic or other. Income level was measured as yes/no to having an annual income of $50,000 or more. Employment status was measured as yes/no to being employed. Education level was measured as yes/no to graduated college/technical school. Analysis Frequency distributions by state were used to assess sample characteristics and identify any issues with the distribution of variables. Multiple logistic regression analyses by state were used to assess the relationship between diabetes status and mental health in older adult females while controlling for health-related and demographic factors. We chose to analyze data from multiple states separately to determine patterns among variable relations across similar samples. Similar results in three or four out of four states were considered evidence for reliable relationships. Any observations with missing data for any variable were removed from the multivariate models. All statistical analyses were conducted using STATA 15.1 (Copyright 1985-2017 StataCorp LLC). Results Descriptive Table 1 lists participant characteristics for older adult females ages 65-75 in Alabama, Kentucky, Mississippi, and Texas. Across states, approximately one-fourth of the participants reported mental health issues in the past 30 days (22-31%) and a diagnosis of diabetes (23-26%). Additionally, the majority of participants reported being overweight or obese (68-71%), about one-half reported having 2 or more health conditions (41-51%) other than diabetes, and few reported that cost was a barrier to seeing a health care provider (5-7%). For demographic factors, most reported white race (67-88%), few

Relations between diabetes status, comorbid conditions, and current mental health in older adult females 717 Table 1. Participant Characteristics by State Alabama Kentucky Mississippi Texas Variable (N=867) (N=1356) (N=668) (N=1714) N % N % N % N % Good Current Mental Health 867 100 1356 100 668 100 1679 100 Yes 270 31 316 23 148 22 438 26 No 597 69 1040 77 520 78 1241 74 Diabetes 867 100 1355 100 668 100 1711 100 Yes 225 26 336 25 162 24 397 23 No 642 74 1019 75 506 76 1314 77 Weight Status 799 92 1268 94 631 94 1544 90 Overweight or obese 544 68 897 71 443 70 1054 68 Not overweight or obese 255 32 371 29 188 30 490 32 Health Conditions (other than Diabetes) 838 97 1305 96 646 97 1666 100 0 144 17 247 19 151 23 441 26 1 274 33 398 31 219 34 547 33 2 or more 420 50 660 51 276 43 678 41 Healthcare access 866 100 1354 100 667 100 1713 100 Cost was barrier to seeing provider 58 7 93 7 35 5 114 7 Cost was not barrier to seeing provider 808 93 1261 93 632 95 1599 93 Ethnicity/race 856 99 1344 99 659 99 1657 97 White, non-hispanic 625 73 1178 88 443 67 1265 76 Other 231 27 166 12 216 33 392 24 Income level 635 73 1029 76 504 75 1377 80 $50,000 or more 183 29 320 31 132 26 509 37 Less than $50,000 452 71 709 69 372 74 868 63 Employment status 863 100 1351 99 667 100 1646 99 Employed 107 12 207 15 84 13 270 16 Not employed 756 88 1144 85 583 87 1426 84 Education level 866 100 1355 100 668 100 1700 99 Graduated college/technical school 212 24 363 27 177 27 587 35 Did not graduate college/technical school 654 76 992 73 491 74 1113 65 were employed (12-16%), and most reported having an income of less than $50,000 (63-74%) and not graduating college or technical school (65-76%). Adjusted As shown in Table 2, the results of multiple logistic regression analysis for older adult females in Alabama, Kentucky, Mississippi, and Texas indicated that after controlling for all other variables in the model, mental health was related to diabetes status in only 2 of 4 states. In those states, diabetic participants were about 2 times less likely to report good current mental health. Mental health was also related to healthcare access in 2 of 4 states. In those states, participants who reported having cost preclude seeing a provider were about 2 to 2.5 times less likely to report good current mental health. However, mental health was related to number of health conditions other than diabetes in all states. Compared to those with zero health conditions, participants in four of four states who reported two or more health conditions other than diabetes were about 2 to 4 times less likely to report good current mental health. Discussion The purpose of this study was to examine the relations between diabetes status and current general mental health in older adult females in the general population. Across states, about one-fourth of females ages 65 to 75 reported mental health issues and about one-fourth reported having been diagnosed with diabetes. The results of the adjusted analysis indicated that current mental health was marginally related to diabetes status (findings in only 2 of 4 states) in older adult females. Prior research indicated that diabetes status was related to mental health [8,10-13]; however, previous studies measured symptoms of depression and anxiety rather than days of overall mental health. Previous research also controlled for HbA1c, diabetes duration, and treatment regimen [2,3,6-9], whereas our study did not. Additionally, we selected older adult women to assess current general mental health and diabetes status and to our knowledge we are the first to do so. The results of this study did, however, indicate that current mental health and number of health conditions were consistently related. Compared to zero health conditions, participants in all four states who reported two or more health conditions other than diabetes were about 2-4 times less likely to report good current mental health. Similarly, prior research found that higher comorbidity was independently associated with higher intensity and longer duration of depressive symptoms [6]. This study also found that current mental health was marginally related to healthcare access (findings in only 2 of 4 states). Thus,

718 Forsberg JM, Flores AM, Plec AA Table 2. Results of Multiple Logistic Regression Analyses Across States Alabama Kentucky Mississippi Texas Predicting Good Current Mental Health (Yes vs. no) Low High Low High Low High Low High Diabetes No ref - - ref - - ref - - ref - - Yes 0.55 0.36 0.85 1.00 0.71 1.42 0.56 0.34 0.93 0.92 0.67 1.27 Weight Status Not overweight or obese ref - - ref - - ref - - ref ref ref Overweight or obese 1.21 0.80 1.84 1.06 0.75 1.50 0.95 0.56 1.62 1.14 0.84 1.54 Health Conditions (other than Diabetes) 0 ref - - ref - - ref - - ref - - 1 0.72 0.37 1.40 0.64 0.37 1.08 1.01 0.50 2.07 0.54 0.35 0.83 2 or more 0.25 0.13 0.46 0.33 0.20 0.53 0.44 0.24 0.83 0.25 0.17 0.37 Healthcare access Cost did not preclude seeing provider ref - - ref - - ref - - ref - - Cost precluded seeing provider 0.40 0.20 0.78 0.54 0.32 0.89 0.58 0.24 1.30 0.40 0.25 0.66 Ethnicity/race Other ref - - ref - - ref - - ref - - White, non-hispanic 0.91 0.58 1.43 1.09 0.69 1.73 0.66 0.39 1.11 1.09 0.78 1.53 Income Level Less than $50,000 ref - - ref - - ref - - ref - - $50,000 or more 1.33 0.82 2.17 1.39 0.95 2.05 1.39 0.76 2.58 1.38 1.02 1.88 Employment Status Not employed ref - - ref - - ref - - ref - - Employed 1.38 0.74 2.59 1.32 0.84 2.08 0.90 0.44 1.83 1.32 0,90 2,94 Education Level Did not graduate college/technical school ref - - ref - - ref - - ref - - Graduated college/technical school 0.94 0.59 1.49 1.19 0.81 1.73 1.27 0.70 2.31 0.98 0.73 1.32 =adjusted odds ratio; =95% confidence interval; ref=referent group; boldface indicates significance (s with not including 1.00 are significant) mental health issues in this target population may be more a result of the current severity and management of one or more health issues, especially if cost is a barrier to health care. Future studies may want to focus on facets of disease burden such as symptoms, severity, activity limitations, or lifestyle changes as related to current mental health and chronic health conditions for older adults. Limitations The BRFSS data allowed assessment of patterns among variable relations in large, similar samples using recent data. However, we lacked information on the severity and management of the participants health conditions, including diabetes, which could aid in understanding the context of the participants mental health issues. Also, we had no data on what medications the participants are taking for their health conditions. This information could be helpful in determining whether their medications are contributing to their mental health, as many common medications have adverse effects of depression and/or anxiety. Conclusion The results of this population-based study may generalize to older adult females in primary care. Primary care providers may expect about one-fourth of their female patients ages 65-75 to report mental health issues and about one-fourth to have a diabetes diagnosis. The results of this study indicated that diabetes status was marginally related to current mental health. In addition, about half of patients in this target population may report two or more health conditions other than diabetes and having multiple health conditions was consistently related to current mental health in older adult females. Thus, practitioners should not automatically screen for mental health issues in all 65 to 75-year-old females based on diabetes status; however, practitioners should screen for mental health issues and multiple health conditions, including diabetes, in older adult females that present with either. Practitioners should determine the severity and management of any conditions, coordinate management and care for all conditions, and refer to psychiatry or other specialties as needed. Because mental health issues were marginally related to healthcare access in this study, providers may want to consider cost in treatment plans for older adult females with multiple co-morbidities, including diabetes, if cost is a barrier for treatment for patients in this target population. Disclaimer No author has any conflict of interest. Source(s) of Support There was no financial support for the conduct or findings of this study.

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